MEDICARE: MR. BRYAN OKOLO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	374700000X	Technician
2	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1821576323
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRYAN OKOLO

Provider Business Mailing Address
First Line	:	1879 SANFORD ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19116-3845
Country	:	US
Telephone Number	:	267-265-7292
Fax Number	:

Provider Business Practice Location Address
First Line	:	1879 SANFORD ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19116-3845
Country	:	US
Telephone Number	:	267-265-7292
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/06/2018
Last Update Date	:	08/06/2018

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